Pituitary Tumor Surgery and CPAP

I expect to be having surgery to remove a ACTH secreting pituitary macroadenoma.

The approach will be through the nose to reach the tumor. Talking to the surgeon I learned they would not want me to use CPAP for about a month afterwards. The reason is a fear that a high pressure in the nose area ( which could be expected even with the nose packed and a full face mask) would increase the risk of material moving from the nasal cavity into the the sinus behind and then into the Sella and possibly the brain. This could lead to infections in area where you do not want them.

I do not know how valid this concern is but it does sound plausible, although the surgeon's advice might be biased towards anything that could increase the risk of infection, rather than the overall effects on health. There may be work arounds such as having a dental device fitted for this period or other solutions.

Anyone here have experience with this issue or any relevant information.

I know someone else who had the exact same thing done, tho' for a slightly different diagnosis, but I can't remember now what they said about using Cpap (it was a couple of yrs ago). I would at least try to find somewhere relatively upright to sleep in/on, be careful about consistency of hours of sleep, etc. etc. But I would also ask the doctor if it was possible for them to check (MRI?) things out in 2 wks postop and see if you've progressed enough to not have to wait the full month (which was likely an estimate - everyone heals differently).

No, I don't know anyone who was in similar situation. I am just thinking about this mask:


Oracle 452 Oral CPAP Mask FitPack with Headgear


This mask was designed for mouth breathers. The inner cushion (shown) goes into the mouth, in front of the teeth and the inner cheeks&lips. The nares are plugged with the provided plugs.

Just using a mask for the mouth probably would not work since the oral and nasal cavities are connected. Their concern seems to be higher pressures in the joint cavity than outside and hence a tendency to force material from the nasal cavity inwards causing infection. I expect to talk more with the nasal surgeon involved Monday, Sep. 30 and may learn more.

I am told to expect to feel very tired for the first two weeks afterwards, and possibly if this keeps me in bed, or close to it (additional problems from a lack of CPAP may not be a major issue at least for this period.

My instinct is that a month may excessively conservative since growing enough new skin to resist the mild pressures exerted by CPAP should not take long (accepting it as given that the nasal cavity may be somewhat dirty and one does not want flow from it into the sinuses and or the brain).

Your predicament is outside my realm of knowledge but I do want to wish you success and a swift recovery when you have your surgery. Do let us know what your doctor says about an oral mask - I'm curious about that. I know all those areas are connected, just thinking when I mouth breathe the air doesn't come out my nose so wondering if just maybe that air pressure would not be at the point of incision. Now I feel the need to study a bit. Best wishes with it all.

I talked to the ENT throat surgeon who will do part of the work. He said to expect to be without the CPAP for 7 weeks. He suggested consulting my sleep doctor on what to do, and that if I did not a consultation with one of their sleep doctors might be required. He thought adding oxygen might be part of the solution, and would reduce the rate of awakening (apparently by lengthening the period before oxygen feel so low as to produce an awakening). I had not heard of oxygen as being useful in the treatment of sleep apneas. I have my doubts partially because I understood that carbon dioxide normally provided the signal for breathing, so oxygen would not reduce awakenings.

Best of luck with your surgery. I was diagnosed last June with a highly calcified macroprolactinoma adenoma on my pituitary gland. Luckily, mine is responding to medical treatment with cabergoline, and hopefully we'll not require surgery. God bless.

I would suggest asking the doctor who said you can't use CPAP post surgery specifically about the oral mask and ask them to explain to you anatomically how your specific incision will be affected by air from an oral mask. While the answer will likely end up being the same, it justs sounds like you thusfar have generalities and I'd want to know that they weren't just giving pat answers without fully understanding what you are asking in reference to the oral mask. They may think you are referring to a full face mask that accomodates both oral and nasal breathing - not the same as the oral mask which is mouth only.

A lot of information gets exchanged on here (and everywhere on the internet) and sometimes info related to sleep apnea is not necessarily exchangeable between obstructive and central sleep apnea. As far as if oxygen might help OSA, I have a friend whose doctor did order oxygen for a period of time. Not as a recommended replacement, but as a "better than nothing" type approach. Theoretically, if an apnea is preceded by a lengthy hypopnea and a person were on oxygen, their level at the time of complete obstruction could be higher than if oxygen were not in place, allowing a bit more time before significant desats. I have no idea overall how helpful the oxygen really is, but if I were in the situation, if I had any indication it could be helpful at all, I'd probably opt to use it. Thing about obstructives is once that airway slams shut, none of the oxygen is getting through. It's a matter of if the levels before the obstruction and how quickly one recovers after it might be affected enough to make the treatment worthwhile. Would love to hear from those professionally "in the know" about this.

Professor,
I just went through the same surgery you're scheduled for --- on 9-20-2013, using endoscopic transsphenoidal surgery, a surgeon removed an ACTH secreting microadenoma (6mm) from my pituitary (Cushing's disease). Like you, I use a CPAP and was *very* concerned about not being able to use it after the surgery. My surgeon said not to use CPAP after the surgery because (understandably) she didn't want air being blown into my brain.
She said I had to wait two weeks.
I'm coming up on the two week point now and have mixed feelings. On the one hand, not having the CPAP is *terrible*. I can't sleep at all. I haven't had more than an hour of uninterrupted sleep in two weeks. So I'm really looking forward to decent sleep. On the other hand, I'm scared - I don't want to cause problems by creating an air pocket in my sella.
Everything I've read on the web has these crazy wait times like 7 weeks or 6 months. I haven't found a single scientific study discussing this, so it seems to me that these numbers being recommended by physicians are being pulled out of the air. I don't know where my surgeon got her 2 week number, but I really like the answer, so I haven't given her pushback on that. She has done several hundred of these surgeries, though, so at least she has the benefit of experience. Yes, I recognize that I'm rationalizing her answer because it's what I wanted to hear.
But I've got to get the sleep thing under control. Also, I've been healing very well, and there's been no blood from nose in the last 12 days, so it seems safe to say that the hole in the sinus is healed over. I even cheated a bit and blew my nose to see if it would disrupt the healing hole, and it didn't - still no bleeding. So, I'm going to risk it, probably starting at the 15 day mark.
If you want to chat offline or get my anecdotal evidence of the surgery, feel free to contact me at brianmeadors at gmail dot com. We're in a small club - only about four in 1 million get diagnosed with Cushing's from pituitary adenomas.

My sleep doctor reported having lunch with a neurosurgeon who did pituitary surgery. He mentioned my issue and was told this surgeon thought 24 hours without CPAP was what he requested, and another neurosurgeon at the table (spinal surgery agreed). This suggests little is known, and I suspect my surgeon is basing his advice on what avoid any possible bad effects on the surgery without consider the health costs of doing without CPAP for a long period.

If anyone has any further thoughts I would like to hear them.

Just using frog-logic, I would figure a lot would depend on the patient.
(age, general health, thickness and healing rate of tissues.)
We might also consider any surgical complications and the pressures needed to stop apneas.
Without second-guessing the surgeon, you might request a progress check for possibly resuming cpap earlier.

I won't give any advice about how long to wait after surgery but I wonder if it would be a good idea to start with the lowest pressure possible to get some decent sleep even if not ideal but less likely to disturb the healing process.

Scary stuff. I wouldn't want to rush back into cpap if my Doc advised against it.

I'm with Julie, rely on things that will minimize OSA such as upright sleeping, and possibly using oxygen to prevent or soften desaturations.
Best wishes on the surgery and recovery,
CN

What about the possibility of a short-term low-dosage Rx of amitriptyline (Elavil) if not contraindicated? I have heard that it reduces the likelihood of apneas by reducing REM while increasing deep sleep which is when the body heals itself anyway... I think. It might be something to discuss with your sleep doctor and surgeon nonetheless.

I had my tumor surgery a on 11/4 at the Mayo Clinic (#1 Hospital for these kinds of tumor surgeries) and Dr. told me one week.

I used mine last night and am so glad - I think a lot of the Drs. are flying blind they want to minimize risk so they throw out a random (very conservative number) to be safe. IE. Don't use your CPAP for two years, etc.